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Attention-Deficit 1

Attention-Deficit/ Hyperactivity Disorder:

A Closer Look

by

Michael J. O’Neill

Submitted in Partial Fulfillment of the

Requirements for the

Master of Science Degree

with a Major in

Guidance and Counseling

Approved: 2 semester credits

-------------------------------------------

Investigative Advisor

The Graduate College

University of Wisconsin-Stout

December, 1999

Attention-Deficit 2

The Graduate College

University of Wisconsin-Stout

Menominie, WI 54751

ABSTRACT

. O’Neill Michael J. .

(Writer) (Last Name) (First) (Initial)

. Attention-Deficit/ Hyperactivity Disorder: A Closer Look .

(Title)

Guidence and Counseling Dr. Robert Wurtz 12/99 32 .

(Graduate Major) (Research Advisor) (Month/Year) (Pages)

. American Psychological Association .

(Name of Style Manual Used in this Study)

This paper examines Attention-Deficit Hyperactivity Disorder. More

specifically, the aim of this paper is to discuss some of the many operational

definitions of ADHD. In addition, this work focuses on the history, etiology,

treatments, and interventions within the paradigm of Attention-Deficit

Hyperactivity Disorder. An extensive review of the current ADHD/ADD

literature was conducted and condensed into this thesis. In the final chapter,

assertions are made toward the need for reform in how the medical and

psychiatric communities deal with this extremely controversial and

misunderstood disorder.

Attention-Deficit 3

Acknowledgments

I appreciate the faculty who have helped guide me through my master’s

program at UW-Stout. I would especially like to thank Dr. Gary Rockwood

and Dr. Robert Wurtz for all their expertise and professionalism over the years.

Without them, none of this would be possible for me.

Dedication

I would like to dedicate this thesis to Michelle, Zachary and the Malone

family, Mom and Dad, and my recently deceased brother Steve. I love you

guys, and always will!!!

Attention-Deficit 4

Table of Contents

Title Page............................................................................................................1

Abstract...............................................................................................................2

Acknowledgments..............................................................................................3

Table of Contents................................................................................................4

Chapter I: Attention-Deficit Hyperactivity Disorder..........................................5

Definition............................................................................................................6

Chapter II: A Brief History of ADHD..............................................................11

Chapter III: Etiology of ADHD........................................................................15

Chapter IV: Treatment and Interventions of ADHD........................................20

Chapter V: Summation and Discussion........................................................... 26

Attention-Deficit 5

Attention-Deficit/ Hyperactivity Disorder:

A Closer Look

Attention disorders, generally categorized as Attention Deficit Disorder

(ADD) or Attention Deficit Hyperactivity Disorder (ADHD), result from

physiological differences in the brain that cause individuals to consistently

display extreme inattention and impulsivity, and in many cases, hyperactivity.

In preschool-age children, signs of inattention include excessive distractibility

and inability to follow simple directions. Impulsivity is indicated by the

inability to wait in line or take turns and reacting to even minor frustrations

with physical aggression. Constant fidgeting, inability to settle down for quiet

activities and constant motion are signs of hyperactivity (Hopkins-Best, 1999).

Attention deficit hyperactivity disorder (ADHD) is one of the most

studied and controversial disorders in child development. This disorder, which

is present in approximately 4 to 7 percent of the childhood population in the

United States, is characterized by behavior difficulties such as inattention,

impulsiveness, and hyperactivity. The child, or adult, with ADHD has

problems starting, staying with, or completing tasks. The result is a life that

may often be chaotic (Durall, 1999).

Attention Deficit Hyperactivity Disorder, one of the most common

childhood disruptive behavior disorders, (DuPaul, 1991) is characterized by a

consistent pattern of inattention and/or hyperactivity-impulsivity (American

Attention-Deficit 6

Psychiatric Association, 1994). Impulsivity is characterized by impatience and

is often expressed in frequent interruptions of others, difficulty in delaying

responses, and intruding on others (Rapport, 1994). Children with ADHD

typically make comments out of turn, fail to listen to directions, initiate

conversations at inappropriate times, blurt out answers before questions have

been completed, grab objects from others, touch things inappropriately, and

have difficulty waiting their turn (American Psychiatric Association, 1994).

DSM-IV identifies the essential feature of Attention-Deficit/

Hyperactivity Disorder as a persistent pattern of inattention and/ or

hyperactivity-impulsivity that is more frequent and severe than is typically

observed in individuals at a comparable level of development. Some

hyperactive-impulsive or inattentive symptoms that cause impairment must

have been present before age 7 years, although many individuals are diagnosed

after the symptoms have been present for a number of years. Some impairment

from the symptoms must be present in at least two settings (e.g., at home and

at school or work). There must be clear evidence of interference with

developmentally appropriate social, academic, or occupational functioning.

The disturbance does not occur exclusively during the course of a Pervasive

Developmental Disorder, Schizophrenia, or other Psychotic Disorder and is not

better accounted for by another mental disorder (e.g., a Mood Disorder,

Anxiety Disorder, Dissociative Disorder, or Personality Disorder).

Inattention may manifest in academic, occupational, or social situations.

Individuals with this disorder may fail to give close attention to details or may

make careless mistakes in schoolwork or other tasks. Work is often messy

and performed carelessly and without considered thought. Individuals often

have difficulty sustaining attention in tasks or play activities and find it hard to

Attention-Deficit 7

persist with tasks until completion. They often appear as if their mind is

elsewhere or as if they are not listening or did not hear what has just been said.

There may be frequent shifts from one uncompleted activity to another.

Individuals diagnosed with this disorder may begin a task, move on to

another, then turn to yet something else, prior to completing any one task.

They often do not follow through on requests or instructions and fail to

complete schoolwork, chores, or other duties. Failure to complete tasks should

be considered in making this diagnosis only if it is due to inattention as

opposed to other possible reasons (e.g. a failure to understand instructions).

These individuals often have difficulties organizing tasks and activities. Tasks

that require sustained mental effort are experienced as unpleasant and

markedly aversive. As a result, these individuals typically avoid or have a

strong dislike for activities that demand sustained self-application and mental

effort or that requires organizational demands or close concentration (e.g.

homework or paperwork). This avoidance must be due to the person’s

difficulties with attention and not due to a primary oppositional attitude,

although secondary oppositionalism may also occur.

Work habits are often disorganized and the materials necessary for

doing the task are often scattered, lost, or carelessly handled and damaged.

Individuals with this disorder are easily distracted by irrelevant stimuli and

frequently interrupt ongoing tasks to attend to trivial noises or events that are

usually and easily ignored by others (e.g. , a car honking, a background

conversation). They are forgetful in daily activities (e.g. missing

appointments, forgetting to bring lunch). In social situations, inattention may

be expressed as frequent shifts in conversation, not listening to others, not

keeping one’s mind on conversations, and not following details or rules of

Attention-Deficit 8

games or activities.

Hyperactivity may be manifested by fidgetiness or squirming in one’s

seat, by not remaining seated when expected to do so, by excessive running or

climbing in situations where it is inappropriate, by having difficulty playing or

engaging quietly in leisure activities, by appearing to be often “on the go” or as

if “driven by a motor,” or by talking excessively. Hyperactivity may vary with

the individual’s age and developmental level, and the diagnosis should be

made cautiously in young children. Toddlers and preschoolers with this

disorder differ from normally active young children by being constantly on the

go and into everything; they dart back and forth, are “out of the door before

their coat is on,” jump or climb on furniture, run through the house, and have

difficulty participating in sedentary group activities in preschool classes (e.g.,

listening to a story).

School-age children display similar behaviors but usually with less

frequency or intensity than toddlers and preschoolers. They have difficulty

remaining seated, get up frequently, and squirm in, or hang on to the edge of

their seat. They fidget with objects, tap their hands, and shake their feet or legs

excessively. They often get up from the table during meals, while watching

television, or while doing homework; they talk excessively; and they make

excessive noise during quiet activities. In adolescents and adults, symptoms of

hyperactivity take the form of restlessness and difficulty engaging in quiet

sedentary activities.

Impulsivity manifests itself as impatience, difficulty in delaying

responses, blurting out answers before questions have been completed,

difficulty awaiting one’s turn, and frequently interrupting or intruding on

others to the point of causing difficulties in social, academic, or occupational

Attention-Deficit 9

settings. Others may complain that they cannot get a word in edgewise.

Individuals with this disorder typically make comments out of turn, fail to

listen to directions, initiate conversations at inappropriate times, interrupt

others excessively, intrude on others, grab objects from others, touch things

they are not supposed to touch, and clown around. Impulsivity may lead to

accidents (e.g., knocking over objects, banging into people, grabbing a hot

pan) and to engagement in potentially dangerous activities without

consideration of possible consequences (e.g., riding a skateboard over

extremely rough terrain).

Behavioral manifestations usually appear in multiple contexts,

including home, school, work, and social situations. To make this diagnosis,

some impairment must be present in at least two settings. It is very unusual for

an individual to display the same level of dysfunction in all settings or within

the same setting at all times. Symptoms typically worsen in situations that

require sustained attention or mental effort or that lack of intrinsic appeal or

novelty (e.g., listening to classroom teachers, doing classroom assignments,

listening to or reading lengthy materials, or working on monotonous, repetitive

tasks). Signs of the disorder may be minimal or absent when the person is

under very strict control, is in a novel setting, is engaged in especially

interesting activities, is in a one-to-one situation (e.g., the clinician’s office), or

while the person experiences frequent rewards for appropriate behavior. The

symptoms are more likely to occur in group situations (e.g., in playgroups,

classrooms, or work environments). The clinician should therefore inquire

Attention-Deficit 10

about the individual’s behavior in a variety of situations within each setting

(American Psychiatric Association, 1994).


Chapter II: A Brief History of Attention Deficit/ Hyperactivity Disorder

ADHD is one of the most misunderstood, misinterpreted, and

misdiagnosed syndromes researched by professionals today. However, the

disorder is treated as though it were some recently discovered esoteric

phenomenon with life threatening properties; when in fact, it’s just simply a

facet of behavior. It is not as serious as most people or researchers wish us to

believe (Calhoun Jr., Greenwell-Iorillo; et al., 1997).

Before 1900, only a few papers existed and described the cognitive and

behavioral consequences of central nervous system injuries like trauma and

infection. In the early 1900’s, Englishman George Still was one of the first to

shift attention to behavioral symptoms of the disorder as unnatural, relative to

normal children at a given age (Pooley, 1995). He also described many

children coming from what Dr. R Barkley, from the University of

Massachusetts Medical School, has described as “a chaotic family life” and

many others coming from “a seemingly adequate upbringing” (Barkley, 1990,

p.4). The overall prognosis for these young people was pessimistic and

“special educational environments” were encouraged.

ADHD has been prevalent for many generations, but under different

names. Ebaugh (1923) was among the first to investigate this topic. Dr.


Ebaugh, a physician and Director of the Near-psychiatric Department of the

Philadelphia General Hospital became fascinated with the disease “epidemic

encephalitis” with respect to its affect on adolescents. In North America, a

1917-1918 epidemic of encephalitis left many children with substantial

behavioral and cognitive losses that were similar to what we now consider

ADHD symptoms. Clinicians continued to recommend treatment and care

outside the home and outside normal educational facilities (Pooley, 1995).

Ebaugh found that children afflicted with the condition were:

quarrelsome, hyperkenetic, impulsive, talkative, moody, irritable, incorrigible,

and suffered from insomnia. His report is among the first to

hyperactivity/hyperkinesis phenomenon. During the past 70 years,

hyperactivity has shifted from one name to another. In the 30’s, the disorder

was referred to as “restlessness,” “irritability,” “overactivity,” and Charles

Bradley’s (1937) term, “organic behavior syndrome.”

Beginning in the late 1930’s, investigators here in the U.S. studied

other possible causes and behavioral expressions of brain injury in children,

noting that hyperactive children displayed similarities to those of primates with

frontal lobe lesions, suggesting pathological defects (Barkley, 1990). This

concept of a “brain injured child” was popular, and it drifted into the 1940’s.

Clinicians advocated educating these children with “minimum brain damage”

(MBD) in smaller, more carefully-regulated classrooms with minimal stimuli.

We now know that more stimulation rather than less is the desired treatment

environment for these disordered children (Barkley, 1990). Also in the 1940’s

, the behavioral term of choice was “distractibility” rose to popularity

(Strauss & Werner 1941), and (Strauss & Lehtinen 1947).

Clements (1966) indicated that since it was difficult to prove that a


child was afflicted with “minimal brain damage,” or “Strauss Syndrome” as it

was commonly called. Perhaps, the term “minimal brain dysfunction” was

more appropriate. In the 1950’s and 1960’s, the concept of MBD faded as it

became recognized as too vague, too inclusive and of little help to indicate

prognosis. More specific labels appeared to describe cognitive, learning and

behavioral disorders (cognitive disabled (CD), Learning Disabled (LD),

Behaviorally Disabled (BD), etc.). The concept of “the hyperactive child” rose

to popularity in the later 1960’s, and a description of excessive activity level

found its way into the American Psychiatric Association’s DSM-II in 1968.

Also in the 1960’s, noted researcher Stella Chess authored papers that

emphasized a behavioral syndrome that may be a result of organic pathology.

Her description included less serious or pervasive behavioral problems. Her

recommendations for treatment encouraged a multi-modal approach including

parent counseling, behavioral modification, psychotherapy, medication and

special education (Barkley, 1990).

Interestingly, Chess and others suspected that the disorder was resolved

by the onset of puberty (Barkley, 1990), although Dr. Parker reflects, “...we

now know that a substantial number of hyperactive children will grow up to be

hyperactive adults” (Parker, 1988, p. 1). Furthermore, Shekim (1990)

contends that the course of ADD/ADHD among adults is extremely variable.

The director of Mental Retardation and Child Psychiatry, Division of Pediatric

Psychopharmacology at UCLA’s Neuropsychiatric Institute, Shekim also

argues that one group of adults may have virtually undetectable signs and

function normally, while another group may have significant problems in

difficulties at work, in interpersonal relationships, family and marital strife,

poor self-esteem, irritability, mood swings and depressive and anxiety


disorders.

Over 2,000 published studies in the 1970’s still emphasized

hyperactivity but also broadened discussion to include impulsivity, short

attention span, low frustration tolerance, distractibility and aggressiveness

(Pooley, 1995). Noted ADD/ADHD authority Barkley clarifies that, “These

writings emphasized the lack of evidence for a syndrome, in that the symptoms

were not well defined, did not correlate significantly among themselves, had

no well-specified etiology, and displayed no common course and outcome”

(Barkley, 1990, p. 12).

During the 1970’s, rapid increase in the use of stimulant medications

with hyperactive children was noted along with increased national publicity

about this Ritalin treatment. Also during this decade, Congress passed the

Vocational Rehabilitation Act of 1973 (Public Law, 93-112). Together these

events seemed to heighten the nation’s awareness of disabilities (Pooley,

1995).

Broadly speaking, the 1980’s and 1990’s have generated considerable

literature, an explosion of learning intervention strategies and more clearly

defined diagnostic criteria. The Diagnostic and Statistical Manual of Mental

Disorders, Third Edition-Revised (DSM-III R), published in 1987, has four

pages of specific information, explanation and diagnosis criteria about

ADD/ADHD; the fourth edition (DSM IV), published in 1994, has eight pages.

This suggests growing public and professional concern about this prevalent

childhood disorder.


Chapter III: Etiology of ADHD

The etiology of this phenomenon has eluded researchers for decades.

Physiological, sociological, and environmental theoretical perspectives have

been exhausted in attempts to identify a link to the etiology of this dysfunction.

The profession is no closer to the answer of causality now then they were half

a century ago (Calhoun, Greenwell-Iorillo, et al, 1997). Goodman and

Poillion (1992) conducted a comprehensive review of the literature to ascertain

a professional consensus relative to etiology and characteristics. After

surveying 39 literature sources, they identified that 69 different characteristics

were attributed to children suspected of being ADHD. In addition, 38 possible

causes were identified for just 25 reports.

Dykman and Ackerman (1993) concluded that there were three types of

attention deficit disorder behavioral subtypes. The first was “attention deficit

disorder- without hyperactivity” (ADD/WO). The second was, “attention

deficit disorder with hyperactivity” (ADDH). The final subtype is, attention

deficit disorder with hyperactivity and aggression (ADD/HA). This study

further illustrates that if consensus is not reached soon relative to cause and

characteristics, this confusion will continue to escalate and confound this

already polemic topic. There is too much attention directed toward labeling


and classification issues and not enough energy devoted toward intervention

and remediation strategies to help parents and educators manage the child at

home and in school. Because of the attention afforded to labeling, too many

students have been misdiagnosed and labeled when most are just being active

healthy children (Calhoun Jr.; Greemwell-Iorillo; et al, 1997). Desgranges et

al. (1995) discovered that scores of children were mislabeled because of many

problems children face today in homes subjected to conflict. Some children

identified as ADHD are actually suffering from other complications (conduct

problems, poor home relationships, dysfunctional families, physical- sexual-

verbal abuse, depression, school anxiety, etc.). Their investigation revealed

that only 3 to 5% of all school age children really suffer from ADHD.

There are several theories that attempt to explain the cause of ADHD;

however, most experts agree there is probably no single cause to explain the

disorder. Instead, a combination of factors related to hyperactivity seem to

interact in varying degrees to cause the disorder. These factors may include

brain damage; poor or inadequate prenatal nutrition and care; maternal alcohol

or drug consumption during pregnancy; malnutrition; abusive home

environments; genetic factors; high levels of stress; food additives or allergies;

and physical, neurological, or psychiatric conditions (Sealander et al., 1993).

For educators and school counselors, causal factors have minimal, if any,

impact on interventions; however, acknowledging the etiology often facilitates

acceptance of the disorder and promotes willingness to try various

interventions (Schwiebert & Sealander, 1995).

Dr. John Durall proposes that, neurobiologically, there is a

developmental delay in very specific self-regulatory management areas within

the prefrontal cortex of the brain. Research has begun to compare anatomical


pictures of the brain, MRIs, with score on psychology tests measuring

inhibition response. (Response inhibition is the initiating major problem in

ADHD). Researchers have found a significant correlation between lower

scores of response inhibition on psychology tests and MRIs that often show a

smaller right Caudate Nucleus and right Globus Pallidus in the right cortical-

striatal-thalamic-cortical circuitry of the brain. This points to the possibility

that people with ADHD may have functional and behavioral deficits that are

related to anatomical variances in their brains.

In addition, during the infancy stages of development, the brain

produces many excitatory messages causing a high level of motor activity with

resultant increased drives for exploration. As the individual moves into and

through the childhood years, these excitatory messages decrease and are

replaced with inhibitory messages. Inhibitory messages allow the child to

pause, think, recall, and resolve. (Remember that ADHD is a problem of

inhibition.) This change parallels a normal maturational reduction of levels of

dopamine concentrations from initial high levels to later reduced levels.

Dopamine is a neurotransmitter that carries communications across synapses in

the brain and is very important to the brain’s braking or inhibiting system. Of

significance is the fact that researchers have found that dopamine

concentrations remain high and do not become age appropriately diminished in

the brains of ADHD hyperactive boys. Other brain imaging studies, PET and

SPECT scans, have also shown support of either structural or functional

differences in an ADHD child’s brain (Durall,1999).

David Henley reports that ADHD is a spectrum disorder, manifested in

a variety of subtypes which are widely considered to be neurodevelopmental in

nature. The salient feature-attention deficits with or without hyperactivity- is


“embedded in a complex array of neurocognitive and psychiatric

vulnerabilities and complications” (Sandler, 1995). Without co-morbidity,

ADHD’s features include inattention to others’ instructions or interactions,

forgetfulness, impulsiveness, difficulties with organization or structure, mood

labolity, and low frustration tolerance, which may result in behavior (American

Psychiatric Association, 1994). These neurobiological dysfunctions may be

the result of dysregulation of certain neurotransmitters, such as dopamine or

norepinephrine, which modulate information processing to the brain (Quinn,

1995).

Although the exact frequency of convergence of learning disabilities

and ADHD is unclear, there is a high correlation between the two disabilities

(Levine, 1987). Frequently, learning disabilities manifest themselves with

situational variability, i.e., some areas of learning are easily mastered, while

others remain elusive. For this reason, investigators, such as Barkley (1990),

view ADHD as a motivational deficit, rather than purely a problem of

attention.

Deviations in behavior may not be apparent when the child is alone,

engaging in activities that reflect a personal interest. With no demands placed

on them, children with ADHD may not present with behavioral difficulties

until they interact with others, such as a teacher, a parent or a peer. Here,

conflicts inevitably arise, for the child with ADHD has great difficulty dealing

with what Barkley terms “rule governed behavior.” The incapacity to

accurately interpret, and then follow, established rules required in social or

school situations often results in interpersonal conflicts with authority figures

or peers. The results may be non-compliance, oppositionality, or

manipulative-type responses, which are tied to the child’s inability to self


regulate. Without self-regulation, a cycle of conflict and negativity becomes

inextricably bound up with the child’s relationship to others (Henely, 1998).

Further complicating this spectrum of difficulties are the co-morbid

psychiatric or neurological disorders, which often accompany ADHD.

Emotional disturbance and oppositional defiance disorders are found in 44% of

children with ADHD, while obsessive-compulsive disorders with ADHD are

found in 13%. Anxiety disorders also fall within the 13% range (Tzelepis,

Schbiner, & Warbasse, 1995). The complex interrelationship between ADHD

and other psychiatric illnesses underscore the need for multi-modal diagnostic

and treatment strategies.


Chapter IV: Treatment and Interventions

Children diagnosed with ADHD need a comprehensive treatment-

intervention plan that may or may not include the use of medication. When

medication is indicated however, the most commonly used are central nervous

system stimulants that include methylphenidate (Ritilan), dextroamphetamine

(Dexedrine), and pemoline (Cylert) (Black, 1992). Ritilan and Dexedrine are

usually dispensed to the student twice daily as directed by the physician. The

peak effects of these medications occur in 2 hours after ingestion and dissipate

within 4 to 5 hours. Cylert is a steady-state medication with effects lasting 7 to

8 hours (Gomez & Cole, 1991).

Of the stimulants, Ritilan is usually the medication of choice and

prescribed for more than 90% of children receiving medication intervention

(DuPaul, Barkley, & McMurray, 1991; Gomez & Cole, 1991). In assessing

the efficacy of stimulant medication, DuPaul et al. (1991) reported that

between 70% and 80% of children treated with stimulant medications respond

positively to one or more doses. The remainder of the children (20% to 30%)

treated with stimulant medications exhibited no response or their ADHD

symptoms worsen.

When a child responds positively to medication, the observed effects

include the ability to sustain attention to task and the inhibition of impulsive


responding. Medication also reduces a number of types of activity, especially

task-irrelevant, nonproductive movements during work situations. Problems

with aggression, classroom disruptive behaviors, and noncompliance with

authority figures have also been shown to improve (Schwiebert & Sealander,

1995). Additionally, the quality of interactions between children with ADHD

and their parents, teachers, and peers may improve significantly (Barkley, cited

in DuPaul et al., 1991).

The use of medication intervention is not without some side effects.

Some side effects may include appetite reduction and insomnia. Other, less

frequently reported effects include increased irritability, headaches,

stomachaches, and motor and vocal tics. In addition, behavioral rebound has

been found to occur in about one third of the students taking medication. The

rebound is a deterioration in conduct that occurs in the late afternoon and

evening following daytime administrations of medication. To date, the only

documented long-term side effect associated with stimulant medication is

suppression of height and weight gain. With discontinuation of treatment,

however, normal growth resumes. Researchers continue to study the effects of

medication interventions (Schwiebert & Sealander, 1995).

Alternative medications, used less frequently than stimulants,

include antidepressants, clonidine, and monoamine oxidase inhibitors.

Clonidine is gaining recognition as a drug of choice for those individuals for

whom Ritilan is deemed inappropriate because of side effects (e.g., tics)

(DuPaul et al., 1991; Gomez & Cole, 1991). Studies are currently being

conducted to substantiate the efficacy of its use. Regardless of the medication

used, it is imperative that the effects be continually monitored and the data be

reported to the physician and the family. School counselors may be in a


position to observe these medication effects or, as the coordinator of the school

team, the school counselor may gather this information and report it to the

parents or physicians. Objective methods of conducting ongoing assessments

of children on medication should include teacher ratings, direct observation

measures, curriculum-based measures, and assessment of behavior to discern

possible side effects. In addition to medication therapy, other interventions to

assist the student in social and academic skill building are necessary. Critical

to the success of any intervention plan is the understanding that no single

treatment modality is sufficient to bring about durable reductions in ADHD

symptoms (Gomez & Cole, 1991; Kauffman, 1993; Sealander et al., 1993).

Another common intervention for children with ADHD is behavioral

interventions (Gomez & Cole, 1991). Essentially there are two areas of

behavioral interventions that focus on (a) antecedents of behavior and (b)

consequences of behavior. The antecedents deal with characteristics of the

environment, the task, and the events that proceed the behavior. Antecedent

conditions include setting and environmental design issues such as type of type

of class, for example, regular versus special class; the structure of the setting;

seating arrangements; and characteristics of the task.

Consequence interventions involve the use of contingency

management. The application of consequences contingent on specific child

behaviors, or contingency management, has consisted of interventions such as

token economy, contingent attention, and home-based contingencies.

Additional strategies include group contingencies (strategies in which

consequences for the whole group are contingent on specific behaviors of

individuals), peer mediated interventions, time-out, response-cost, and over-

correction (Schwiebert & Sealander, 1995). Contingent attention is the most


universally used management technique. In this technique, teachers and/or

counselors give both positive and negative verbal feedback with a high degree

of frequency. Negative consequences, such as reprimands, may be needed in

addition to positive reinforcement for satisfactory behavior management.

Reprimands are most effective when they are given in a calm, firm, consistent,

and immediate fashion. Additionally, eye contact, proximity, and overall

professional posture increase the effectiveness of the reprimands (Abramowitz

& O’Leary, 1991).

Token economies are an example of a consequence management

program. A token economy involves awarding or removing token points to

children depending on predetermined desirable or undesirable behaviors. The

power of this approach to motivate children and to achieve an excellent level

of on-task behavior and academic achievement is well documented (Fire,

Beaker, & Near, 1993; Games & Cole, 1991). Combined with contingency

management from counselors, teachers, and parents, token economies may

significantly improve peer sociometric and teacher ratings of hyperactive

behavior (Landau & Moore, 1991).

Another intervention, home-school contingencies, consist of programs

that combine school and parent efforts to improve children’s social behavior.

Typically, a teacher completes a 3 to 5 item checklist that specifies whether the

child has met identified behavioral goals for the day. The report is sent home,

signed by the parents, and returned. The parents provide the appropriate

consequence at home by applying contingencies that have already been

developed (Schwiebert & Sealander, 1995). Advantages to this approach

include daily communication between parent and teachers, it is not time

consuming or costly , parents have access to a wider variety of potential


reinforces, and generalization of treatment may be enhanced because of the

requirement of delayed gratification (Kelly & Career, cited in Abramowitz &

O’Leary. 1991). The success of this intervention seems to be dependent on all

involved parties understanding the procedure and on close cooperation

between teachers and parents.

Peer-mediated interventions have several advantages over

counselor/teacher-mediated strategies and may result in significant positive

behavior changes. Advantages include the fact that students themselves may

more closely observe each others’ behavior, generalization of behavior across

settings may be facilitated, and peer-mediated interventions are less time

consuming for the counselor/teacher. Peer-mediated reinforcement and group

contingencies can be divided into three types including (a) interdependent, in

which the behavior of the entire group determines whether the group receives

reinforcement; (b) independent, in which a set of contingencies is applied to

the entire group, but each child’s behavior determines his or her eligibility to

receive reinforcement; and (c) dependent, in which the behavior of one or

several target children determines reinforcement for the entire group

(Sealander et al., 1993).

Time-out, response-cost, and overcorrecting are all punishment

techniques. Time-out from positive reinforcement is a well documented and

effective technique for reducing undesirable behaviors. Caution should be

used, however, and careful planning and implementation are essential for the

success of such a program (Schweibert & Sealander, 1995). Response-cost. a

preferable type of contingency, is the withdrawal of privileges or rewards from

the student. Over-correction, another negative consequence, requires the


student to make restitution or engage in a more appropriate form of behavior

(Kauffman, 1993).


Chapter V: Summation and Discussion

In summation, ADHD is one of the most studied and controversial

disorders in child development. The child, or adult, with ADHD has problems

starting, staying with, or completing tasks. The result is a life that may often

be chaotic. This disorder is present in 4 to 7 percent of the childhood

population in the United States. Current research theorizes that ADHD is a

developmental disorder of self-regulation. The person may show little

hindsight, forethought, or preparatory action. This may cause serious

impairments in social, academic, or vocational functioning (Durall, 1999).

That is not to say that ADHD is entirely a negative condition. The

same brain functioning that causes problems for a child may also give that

child qualities for success, such as intuition and spontaneity, excitement and

energy, creativity and artistic skills. Some of the world’s smartest, most

creative and highest functioning adults have at one point been diagnosed with

ADHD. A comprehensive treatment program, an educational understanding of

ADHD, and a focus on the skills and positive qualities that the child possesses

are extremely important for the child’s success.

The zeitgeist for treating ADHD seems to be rapidly evolving. Where


once medications like Ritilan and Clonidine were apparently over-prescribed,

alternate treatment paths are being taken. The foremost being behavioral

contingency training. As reported earlier, this training must motivate the child

to overcome the destructive impulses which they seek to gratify. Such

programs are usually based upon offering tangible rewards, such as points,

prizes, or privileges in return for compliance. The therapist and child agree

upon a contract which spells out each desired behavioral objected, as well as

the consequences of failure.

The use of behavioral contracting is not without limitations if utilized in

isolation from other treatment approaches. Some researchers have found that

all children, particularly those with ADHD, require a constant escalation of

reward levels. These children become easily habituated by any long-standing

stimulus (Linn & Hodge, 1982).

Personal experience from working with ADHD adolescents at a

residential treatment center supports this assertion. It seems that the ADHD

child loses interest at a higher level if the same “behavior equals reward”

formula is maintained too long. Desired behaviors and compliance was

increased when rewards were varied or rotated (i.e. Monday’s reward for

earning all possible points was staying up until 9:30 p.m.; Tuesday’s

reward for “perfect points” was quality one-to-one time with the staff member

of the resident’s choice). But again, this intervention is not without flaw.

Many children with emotional disturbance and conduct disorders see behavior

modification as a form of low level bribery (Henley, 1997). This feeling seems

to increase with the age of the child. Many ADHD children allude to the fact

that they feel like a “lab rat in a maze”, or that they are “chasing a carrot on a

stick while running on a treadmill.” Behavior training relies solely upon


external controls for motivation, but because the locus of control is external,

coming from figures in authority, such procedures rarely become internalized,

with the result that the child becomes reliant upon others for control. In

addition, it is ethically troubling that this type of subtle bribery serves as the

main impetus for appropriate behavior.

Etiology of this disorder is an elusive entity. It seems that the mental

health community is nowhere close to consensus in this area. Physiological,

sociological, and environmental theoretical approaches have been exhausted in

attempts to identify a link to the etiology of this dysfunction. This may be

because there is too much attention directed toward labeling and classification

issues, and not enough energy devoted toward intervention and remediation

strategies. Resultantly, there seems to be widespread misdiagnosis and

mislabeling errors (regarding ADHD) across the medical world. Many

“normal,” “active” children have been mislabeled as ADHD.

Most experts agree that there is no single cause to explain the disorder.

Factors may include brain damage; poor or inadequate prenatal nutrition and

care; maternal alcohol or drug consumption during pregnancy; malnutrition;

abusive home environments; genetic factors; high levels of stress; food

additives or allergies; and physical, neurological, or psychiatric conditions. It

is important to remember that individual life circumstances for ADHD children

are as unique and interrelated, as the varying combinations of etiological

factors that contribute to this disorder.

In today’s climate of uncertainty and inconclusivness regarding ADHD,

it is important to recognize how much we have to learn to fully understand the

dynamics of this disorder. The incredible amount of confusion over etiology

and diagnosis of ADHD became very evident as this subject was researched.


Multiple future generations of young adults depend on our knowledge and

professional exploration of this highly controversial disorder. It is imperative

that we (the medical and psychiatric professions) attempt to ascertain a greater

understanding of ADHD and censure the trend of over-diagnosing and over-

labeling that seems to be diminishing, yet prevalent.

The importance of this topic cannot be stressed enough. M. Levine

summarized the dangers of mishandling cases of perceived ADHD in children.

“So much is at stake. Children who experience too much

failure early in life are exquisitely vulnerable to a wide

range of complications. When these children are poorly

understood, when their specific problems go unrecognized

and untreated, they are especially prone to behavioral and

and emotional difficulties that frequently are more severe

than the problems that generated them. It is not unusual

for such children to lose motivation, to become painfully

(and often secretly) anxious about themselves, to display

noncompliance, to commit antisocial acts (including

substance abuse and delinquent activity), and to lose an

enormous amount of ambition” (LeVine, 1994).

When people lose ambition, they lose hope. And without hope,

opportunity slips away as surely as death someday arrives (Pooley, 1995).


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